Episode 188: The ICU Revolution at Mercy San Juan Medical Center - Part 7 with Dr. Jodi Coates
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This is the Walking Home from the ICU podcast. I'm Kaylee Dayton, a nurse practitioner and ICU consultant. I help teams create awake and walking ICUs through evidence-based sedation and mobility practices. By hearing from survivors, clinicians, and researchers, we'll explore how to give ICU patients the best chance to walk out of the ICU and go home to survive and thrive. Welcome to the ICU revolution.

Thank you so much to all those that voted in the Best of Nursing Award competition. Awaken Walking ICU won Best Nursing Innovation. This is such a tribute to Polly Bailey and Louise Bestian, the true nurse innovators that founded an Awaken Walking ICU process of care in the late 1990s. If you haven't listened to their episodes, go back to episodes...

21 and 26, inherit from them directly. This is also a win to all IC revolutionists throughout the world. Some of you have been working on this since the early 2000 and teens. Some of you started after you listened to this podcast for the first time in 2020. Some of you are just learning about this revolution. Nonetheless,

it is everyone's win. It is acknowledgement that this is a life-saving transformation in critical care medicine. These changes really don't happen overnight. For most revolutionists, it takes years of perseverance and fortitude. I'm excited to have Dr. Jodi Coates share with us how she really magnified her role as the medical director and led her trauma ICU to become an awake and walking ICU.

Dr. Coates, welcome to the podcast. Thank you. I'm beaming because I've waited for like years to say that. Will you introduce yourself to us? Yes. So my name is Jodi Coates. I am a trauma surgeon and emergency general surgeon at Mercy San Juan Hospital in Sacramento, California. I'm the trauma medical director for our hospital. We are at a level two trauma center. And I have been there for about 12 years now.

Wow. And so you as a trauma surgeon, trauma intensivist, how are you trained to manage patients on mechanical ventilation?

Well, when I came through my training, I came through what I consider to be a very rigorous and really good program for ICU level care and also trauma. Specifically, I trained at UC Davis here in Sacramento, which is very trauma heavy to the point that most junior residents feel like there's no way they would ever want to do trauma because they've already done so much trauma. But a lot of senior residents, by the time they

are trying to decide on their life path actually decide that that is what they really love to do. And maybe some of that's brainwashing. I don't know because we do so much of it. But we do get a lot of ICU experience at UC Davis. When I came through, we were exercising some of the practices for how I manage ICU patients now. We were

I'm doing spontaneous breathing trials on the ventilator. Actually, my training program, I feel like was quite progressive in terms of sedation. We really had almost nobody on continuous sedation when I was a resident, even on a fellow. But we did still use a lot of sedation. We didn't have continuous drips, but our orders were usually like one to 10 milligrams of Versed Q1 hour PRN. One to 10 or one to 18.

And it was rare that that much of it was used, but that was our standard order set. So we had some sort of analgesia, but almost every patient had sedation as an option, even though it wasn't common to use continuously.

But otherwise, we got pretty good at vent management, I feel like. But it was very unusual to have a patient that was really very alert or interactive while on the ventilator and in the ICU. Really for me until just recently because it wasn't common in my training. And then when I started my practice out after training, a lot of patients were managed with continuous sedation. Even that was something we were trying to move away from.

quite a while until I would say we had a little bit more of a intentional direction the last couple of years. Yeah, having patients really wide awake and on the ventilator, except for within the 30 minutes before we would extubate them was pretty rare until recently. And what shifted your perspective? What led you to see beyond that? So my journey in this whole process started, to be quite honest, with Dr. Peter Murphy, who is one of the medical intensivists at Mercy Semblan.

He, a few years ago, recommended to the other critical care physicians throughout the hospital, medical, surgical, neuro, that we read Dr. Ely's book, Every Deep Down Breath. And I love book recommendations. And I personally have a lot of respect for Dr. Murphy. And I didn't really know much of what the book was about, but I got it and I started reading it. And

It took me a couple of chapters to really get into it. And then once I did, I could not put it down. And once I was done with it, it was, this was like, I had a single mindedness about making this happen at our hospital. That was really the pivot point for me was truly gaining more of an understanding of what life was like for most of our patients after they had been under our care through no malpractice.

malintent of the providers, of the nurses, of the physicians. But just because of the nature of the beast, I really had no idea that not only some patients, but the majority of patients had such significant disability after the ICU, quite honestly.

And so once I read that book, and then once I started paying attention to how things could be with the right stories, and honestly, your podcast was a big part of that, but reading and learning about different places that have implemented these things and the stories in Dr. Ely's book, and then it just became something I not only could I not ignore, I could not unlearn, but it just wasn't even really an option aside from figuring out how to do this within my own practice at my hospital.

And so what was that like having this huge awakening, learning these things, like listening to the podcast on the way into work and then get into work. And now you're in an environment in which the culture is very established. And we talked to your nurses a few episodes ago about what it was like for them. But as a medical director, what is it like to have that kind of weight of responsibility? Yeah, absolutely.

the care and management of patients in your ICU. Right. I think you put it really well, having to operate within an established culture because...

It started to become something that I would just start talking about and talking to people about. And I was talking to Dr. Murphy and Dr. Bistrong and Dr. Brucha and some of our other intensivists that were aware of these things and also on board with wanting to make the change. But I think we all felt a little bit, and I know I felt a little bit stuck in how to make the change.

While at the same time, seeing patients that were in a state that I knew they probably didn't need to be in and that it was causing harm as I saw it by that point and knowing I could only do so much. And quite honestly, initially, when I would try to make it just doesn't work to be the only person or to be in a minority of people trying to make changes when you work within such a collaborative system like we have.

Our group, we manage patients. It's a service-based group. So when you're on call, you're managing the service. But when you're not on duty, you're not managing those patients. And so you don't really have, say, from start to finish on an individual patient's care.

You have some input and we're a pretty small group. And so we talk to each other a lot, but unless everybody sees it the same way, you can manage a patient one day with no sedation and it's very likely going to be turned back either the next day or at night or whenever you're not around. Unless everybody understands why not to and what things look like if you don't. So there were several months in there where it was pretty, it was just emotionally draining because I felt like

This is it doesn't have to be this way. And it was hard. But I love the notion of there being a tipping point. You just got to keep going in a certain direction and get enough people on board and have enough people really be exposed to understanding the why. And then eventually the opposite is true. It's like a it's like a momentum that you can't stop because it's reached that critical point of enough people understanding not only why, but how.

and then it's feasible. I remember a couple of very specific instances. One, when I was first, I had finished the book and I was actually getting ready to do a lecture at our institution for one of our education days. So one of our trauma education days, our trauma symposium, my lecture was

was going to be on this on ICU liberation and the bundle and on PICS. And I was in the OR a couple of days before the talk and had a case that was like, it's every trauma surgeon's dream, quite honestly. It's like a gunshot wound to the abdomen, but hit almost everything in the abdomen. And I say dream because I'll skip to the end. The patient did very well, not only survived, but did very well.

But it had hit everything, the liver, the spleen, the stomach, the pancreas, the colon, the small bowel, a kidney. It took the path of most structures and went through the diaphragm and the lung as well. So we did, of course, a damage control operation and the anesthesiologist tried to be proactive and ensure a smooth transition to the ICU. He said, what sedation are you planning to use in the ICU? And I said, actually, we're going to try none.

And that was literally the first patient that I had done that on, like from the very beginning, especially one that was that sick and injured. And I got even from my own partner that I was operating with. They're like, what are you talking about? And I was like, well, first of all, right now, he's too shocky to really tolerate any sedation because blood pressure was pretty low. He was under anesthesia. But I was like, we're going to try to do none. And if we need a little bit, we'll try a little bit of Presidex. And that was the only thing I ordered.

And his nurse that night was very frustrated with me because his blood pressure was never high enough to actually start the precedence. But it turned out he didn't need it. He didn't need sedation. We kept his pain under control. And when they came back,

to get him ready for his next, his take back operation. A couple of days later, the anesthesiologist came to me and was like, I have never seen a patient that injured, that critical with an open abdomen, who's that wide awake and interactive and able to write and sign his own consent and write down questions and clearly understand the discussion. And for me, I think have these stories of these Hallmark patients once we started doing this, but that was one of my biggest, like actually putting it into practice, seeing it work.

and seeing the effect on other people of seeing it work. And that guy did so well. He went back to the OR one time. We got him all finished up and closed up. He never was delirious. He got extubated. I think he actually, if I'm not mistaken, he might have been extubated before his last trip to the OR. So then he got intubated and extubated for the OR. And he didn't remain on the vent. He was out of the ICU in a few days. And then it was almost like a bowel obstruction patient. Like we were just waiting for his intestines to work again and set him and went home. It was just

unheard of up to that point for a patient that's severely injured. But yeah, the individual patients were hard for me until we could really get things into place as a system to try to move these practices forward more intentionally. Well, I think it is so courageous of you to just go for it. Do something that you've never done before, but you believe in. You read the book, it was in the podcast. You could see the logic behind it and you had a hope, faith that it would work.

But to be the first one to say, we're going to just let him wake up and you've never done it before. And it was someone so critical, who's likely to have so much pain. And if it didn't go well, the rest of your team, that would paint the whole, I don't want to say experiment, but the whole journey. Right, right. But you had enough guts to just go for it. That is the definition of a revolutionist. To just say,

I understand the harm that we're doing. I'm going to do something different. I've never done it before, but I'm going to give it a try because I know that the alternative, I know that what we're doing as a standard is not working and not helpful. And there are risks involved with that. So why not just see what he needs? Why not just let him wake up? And that was really impactful to your team to be able to see it, even though that they were frustrated. Yeah. And that's hard too, as a physician, you're the one in charge of the orders, right?

But you're not the one constantly at the bedside with the patient. You also, especially as a medical director, but as a physician, period. You have to keep good relationships with your nurses. They need to be heard and respected and their opinions need to be considered and their experience at the bedside. So how did you navigate that when your team didn't have extensive training?

They hadn't been doing all the research that you had been doing. They didn't see it the same way. They still saw patients as sleeping and that you were depriving them of restful, peaceful sleep. Right, right. Well, I think, honestly, I think there's a couple of factors. Like you said, they need to see you as caring about

how it affects them as well. And that's always been important to me. I hope that I come across as a physician who does care about the well-being of the nurses and want to see everybody have not only job satisfaction, but get out of it the reasons that we went into it, which is for the care of the patients. And because for some reason, people in the medical field have this internal drive that that is what makes us tick, like that we get satisfaction out of seeing people do well that we have helped. And so

I think the biggest factor is just understanding the why, honestly, because that's what did it for me. It's like the people I would talk to once more and more people started to read the book or just listen to the stories. The common thread is once you know, you can't unknow. Like you just there's no way to pretend that you don't know that you don't know this anymore once you've

been exposed to it. And so I focused on, we round, do multidisciplinary rounds at the bedside in the ICU. And so I really focused on trying to educate in real time.

One of my favorite comment, I mean, it's my least favorite, but also my favorite because it gives you the opportunity to speak to it is on somebody's. If I was in that position, I would want to be sedated. And I'm like, actually, you wouldn't. I used to think that, too. But then when I learned what people under sedation are actually experiencing, believe me, you would not want to be in that situation. And then we talk a little bit about it. And then I really do try to encourage people to like explore for yourself. Look this up.

read the book or listen to the book. Audiobooks is one of my favorite things now because it's something that I'm in the car anyways, I might as well be listening to a book and passively reading. And so the podcast and audiobook and the book and just really pay attention to what it is like for these patients. Because you're right, you want to think about it. All of us should think about it is what would I want in that situation? If I'm in the hospital or I'm in the ICU or my loved one is,

What do I want them not only to have to go through, but how to come out on the other side? And what does that really look like? But to be able to implement that, we have to know what that really looks like. And so I think it's all about education, because once people know that in this field, they're going to do the right thing, because that's why they're in it in the first place. It's just that for so long, we didn't really understand what that was and what that meant and what it's like to be in that situation.

And that it wasn't part of your medical training, not part of anybody's training to know the patient side of it and to know about this really lethal organ failure that we're causing. Right. I see it's a phrase that we go this long without knowing the reality. And as a medical director and as a physician, you're teaching during rounds. I could see that you did a really good job of that.

that the team felt really supported, that it wasn't just, you were just seeing the orders in the MAR and then walking away or saying, turn that off and walk away. But you were there explaining why you were physically present at the bedside to help with these patients, to support the nurses. And I heard from the team that they felt that. They knew that you were really invested in this and in them. But there are so many logistics that go into this.

How to manage these patients without sedation? This being new to you, also this being such a complex process of care, how do you go about bringing this huge system-wide change? Because I think a lot of pressure comes down to medical directors who always say, well, leadership should do this.

Well, they need to make it happen. It's all up to you. You've never done this. And it's, again, very complex. What is that like to feel like you have to bring the system wide changes with all these barriers? Well, yeah. So that's... I think that's the next thing. The first step is people really have to understand the why. But then there's a very, very, very big how. It's not just why, it's how. And...

Like I said, when I really got interested in this, I used the next opportunity I had to give a talk at our education day to really go through the logistics and the literature and the data and the hallmark studies.

but intermix patient stories in there and some stories from my own family and try to really personalize this because it's mostly nurses at this educational conference, but there's some other disciplines too. There's therapy and physicians are invited and it's for anybody that interacts with trauma patients. So floor nurses, ICU patient, ICU nurses, ER nurses. And I got some mixed feedback after that lecture. Most of it was pretty positive and

To be quite honest, people don't usually give me negative feedback to my face. So I hear it a second. But I did hear some things after that talk, which were along the lines of, oh, this is just another sort of

attempt to shove the bundle down our throats. One person did tell me this is the best way that I've ever actually heard the bundle explained and that it helps to understand the individual components and why they are even components and what this bundle even is, because I think it was gone about the wrong way that the bundle was something people had heard of. It was not a new thing. It's not like this was all the terms I was using were landmark terms. But

But to me, the concepts really were landmark. I had been writing in my notes for years, A to F bundle being applied without really truly understanding what that even meant. Because quite honestly, I think it was presented to physicians and nurses a long time ago as this is something you have to do. But it was never really fully explained what that means or why. Yeah. And so I think for nurses, especially who, like you said, are doing really the brunt of the work throughout the shift at the bedside of these patients.

They're being expected to chart that they're doing something. But if you don't give them the logistical how and you don't also give them the support, and then you're coming with an even more focused expectation, it just feels like more work and with less hands and how. And so I think that was a lot of the very clear and appropriate messaging from nurses, which is that we're not opposed to doing this. And especially as we understand how

why it makes sense. But if you want it to be done, you're going to have to help us figure out how and we need the resources because it can't just be this is more of an expectation for what nurses have to do with less. So when you say leadership, I think it's on all levels. It's not just the physician leadership, it's nursing management, then physician leadership and physician management, but also the administrative support within the hospital.

And I feel like our administrators really in the last few years have done amazing things to help out with that as well. So logistically for us, the way that we made this culture change was after I read the book and listened to your podcast, I know I reached out to you directly and was like, how, how do I make this happen in my hospital?

And you had a few suggestions and offered to do some training and to meet with anybody that it would be helpful to meet with at the hospital to help explain not only the benefits to the patients, but the benefits to the system, right? Because obviously we are a system that has to take care of a lot of patients and it requires a lot of money to do that. And people initially see this as something you're going to lose money over instead of something that the hospital really is going to save a lot of money over. Not only money, but lives. We care about the lives.

But appropriately so to keep the hospitals going, they have to care about money on a certain level. So once I started to talk to more people, I realized that several people are in our system already had been focusing on wanting to do this for a while, had brought it up a few times. And so we got together our

Our critical care educator and our ICU director and some of the other intensivists got together and said, we think really the first step is we got to get administration to understand the value of this to the hospital as well.

And then they can help us with the lift of how we're going to implement it and eventually get the resources down to the nurses and the therapists, the respiratory therapists and physical therapists to make it happen. And I think it really does require, like I said, individual people understanding why and wanting to.

you need, but it's not going to happen unless you do have a systematic approach and the ability to change the culture within the hospital. That was a big thing. You came and gave a talk that several of our administrators were there for, as well as ICU physicians and nurses and about all the benefits to the hospital and to the patients. And after that happened, there really was a lot of, then it was more of an intentional, how are we going to do this logistically? What do we need?

What additional staff do we need? How do we need to direct the staff? How do we train the staff? What does that look like? And then things started to happen. And I said, I could see like eyes starting to light up when I talked about the financial benefits. And I said, I know you're salivating at this huge return on investment, but that doesn't mean that you just turn to your clinical leadership and say, okay, no sedation, get them up.

It is not that simple. You need to be turning to them and saying, what do you need to be successful? Because you will have 20 times the return on investment, at least when you do actually provide the tools needed to be successful. And I felt like they really received it well and heard what you were saying. I'm hoping to interview them as well to get their perspective, because I think there's a lot to learn about the administrative side that a lot of us clinicians don't really understand. And it's important to be able to speak their language.

because they can really make or break this kind of initiative. Sure. Yeah, for sure. What kind of impact did you see? Obviously, when we started the training, it wasn't just a light switch. Everyone was like, oh, the Dayton team is coming and we're just going to do this. So for you as a medical director, how did you support the team?

During all those hesitations in episode 185, you had a group of your trauma nurses talking about the hesitations that they had, the reservations that they had. How did you help support your team to keep them open to the training that they were receiving? If you've been listening to this podcast, you're likely convinced that sedation and mobility practices in the ICU need to change.

The ICU community is facing incredible difficulty with the trauma from the pandemic, staffing crisis, and burnout. We cannot afford to continue practices that result in poor patient outcomes, more time in the ICU, higher healthcare costs, and greater workload for the ICU team. Yet the prospect of changing decades of beliefs, practices, and culture across all disciplines of the ICU is a daunting task.

How does this transformation start? It can begin with a consultation with me to discuss your team's current practices, barriers, and to formulate a plan to help your ICU become an awake and walking ICU. I help teams master the ABCDEF bundle through education, consulting, simulation training, and bedside support. Let's work together to move your team into the future of evidence-based ICU care. Click the link in the show notes of this episode to find out more.

Sure. So I think for me, my group, the physicians and APPs that I work with know that at any given time, well, and sometimes it's very pervasive and long lasting. I have my soapbox issues. I have my things that like really I harp on a lot or that I revisit a lot or that I mentioned in our meetings and in our meetings.

sign outs. And this became one of those things on the clinical side of things. Every time we had a meeting or every time we reviewed a patient in M&M, I would review the sedation practices we had used and many episodes of delirium and how long it took to get them out of bed and how long they were in the hospital. And it was one of the things we felt

focused on. And I started encouraging people to try them without sedation or don't even put the orders in for sedation unless you assess them with the nursing staff and determine that you need it and that there's not other ways. Maybe they need their pain better controlled, or maybe they're just restless. Maybe there are nurses have gotten so good at figuring out

What is agitating a patient? Now it's just, I don't want to say night and day because it's not like they were terrible on this before. It's just, it's hard for anybody if a patient's sedated to figure out why they're upset or why they appear physiologically. If they get tachycardic, their blood pressure shoots up or they start getting really restless and they start pulling on things. You don't know when they're sedated if it's because...

They're in pain because they're withdrawing from something because they, their Foley's clogged and they are feeling the need to urinate. But now it's like,

the nurses, by the time they come to you and even say, I think we might need to use something else. They've already looked at all of those things. They've already figured out. And a lot of times they'll say like, oh, they were really agitated this morning. It took a couple of people in there to settle it down. But then I realized he needed to poop. And now he's just chilling and he's happy and he's looking at his phone or whatever. So we talked about it a lot and I talked about it a lot. And it just, I would joke like, I know, I know, you know, Coates is going off on a sedation thing again or whatever. Like,

mobility stuff. But I think especially leading up to your visits and your training, I tried to use any opportunities I had for my for education or talks or lectures.

for that, for that topic. And then on rounds, we would talk about it. In our meetings, we would talk about it. And then leading up to your visits with the nurses, I would try to, while I was on the job in the ICU, talk about like, oh, well, when Kaylee comes, when Kaylee's team comes and they're going to help us learn how to do this better or whatever. And there was definitely skepticism. I think they mentioned in the nursing episode that they did that somebody, I think it was Dan, had said like, well, who died and made Kaylee king or something or whatever.

one of our NSMs and like, who is this person who's supposedly going to come in and tell us how to do our jobs? I think that was part of the feeling of what this was going to be. And again, I mentioned we need administration to help us make things happen. But I think also the fact that they knew that this was supported by administration, there was still a lot of cynicism about like, what are they trying to make us do? Like there, there still was a lot of feelings that

They're just going to expect more work, more results, more return with less. And this is just another person being brought in from the outside to tell us what we have to do. I encouraged my surgeons, if at all possible, especially if they were on duty, to try to attend some of the simulations and the trainings. But even if they were unable to attend them, I sent out the resources and sent out the packets and the checklists. And we had talked some about the book. And it's just, I think just the more...

people hear about it and see it and are reassured by it. And there was some resistance for sure, I think on all sides. And I think most of that resistance is just born out of uncertainty about what is being accepted of me. There's an appropriate level of cynicism sometimes or a learned level of cynicism when people are being asked to change practices. Yeah, they talk about having been hit and hit and really, really

wrestling some of your complex abuse patients. And I've lived it. I've done it. Ironically, I've done it more out of my awake and walking ICU than in my awake and walking ICU. And it wasn't until years later that I actually tied it all together to realize those patients were probably super delirious and we had made making it worse. And it was all escalating because of the things that we were doing to them.

Whereas in a wake walking ICU, delirium wasn't so common. It also wasn't as severe. And we had a whole team know how to respond to those emergencies. So I could understand their reservations and thinking, yeah, if you that's all you experience about having a patient quote off a station, then that's what they expect is that every patient is going to be a bucking rodeo. Yeah. So they at least had some successes. Like you've described those early right away sedations off no delirium.

And that really helped open them up a little bit by the time I came and noticed that I saw you had a patient or two that was intubated and totally awake, hanging out. So cool to see. But then the question was, how do we standardize this and how do we make this sustainable for every patient? So how do you feel like formalized simulation on site, hands on training?

help take your team to the next step? I think it's always helpful to be able to practice and have hands on and be able to ask questions in real time and get honest answers and not feel like they're having the wool pulled over their eyes or not feeling people are sugarcoating things too much. I think that one of the biggest benefits to having you guys on site was actually your ability to sometimes intervene on real patients we had in the ICU at the time.

And so most of the simulations were with somebody from your team or somebody from one of our teams that was the patient. And we were talking through scenarios and bringing up issues. But there were a few patients that were in our ICU and you guys rounding with us and overhearing some things and making some suggestions. Or I would ask some things like, what have you seen done that's worked in these scenarios? Or I would sometimes call you or text you and be like, I...

What should we try? Because I don't just want a bunch of sedation and be turned back on or, and seeing those successes. I think every time somebody saw those little things actually work and help,

that's what really allows the change to happen. You know, my sister is an ICU nurse too. And when we first started talking about this, she was, I got the same look from her that I got from most of the ICU nurses I work with, which is get out of here with those expectations and expecting me to do more with less. Yeah. If you expect me to try to walk out of a room and a patient who's not sedated and not restrained, and they're not going to pull everything out and make my job harder or hurt me or themselves, like you just literally don't know my job. And

And she also became a total convert and started using these practices in her own patients as a nurse. And I remember one time her telling me like, it's amazing. Like they're doing their own oral care and they're doing like half the things I used to have to do for them. They're doing for themselves. And it makes my heart skip a beat to see them reach up toward their mouth because I automatically think they're going for their tube. But the awake ones are not for the most part. And some of the time they do and they're right. That tube's ready to come out. Yeah.

just don't like it to come out that way. But, but yeah, I think the onsite training was helpful because it allowed people to see you and your team as real people who have real experiences, who are on or have been on the clinical side of things. And you're not

Nothing against our administrators. We have very good administrative support, but you're not just an administrator coming in and telling them expectations. It's helping figure out how to do this thing that once everybody learns about it, they really do want to do and choose to do and enjoy doing. And the webinars we talked, it was more didactic. We're talking about the research, the big picture of what we're doing and a little bit of the practical things. But really, you have to have that foundation of knowing why.

What's actually happening with our current practices? That alone is it's extensive. Yeah, really have to know a lot of things in order to be willing to try something different and to be able to have tools to critically think through each scenario. But then the logistics of how to prevent and manage agitation, how to mobilize someone, how to talk to each other, how to determine when sedation is or is not appropriate.

All of those things is its own training. And so we did the webinars as a foundation. Then the simulation training was opportunity to talk through a lot of those practical logistics and the entire team, every discipline was there so that they could talk to each other, express their perspectives to each other and really collaborate. And we used your own case studies. So these weren't just unrelatable patients. These were your actual patients within the recent few months.

and talk through what could have gone better. Why was this difficult? How did this impact you? What would you do differently now? And yeah, to be able to weigh in on current patients and seeing real time the impact of these ethereal concepts in practice and see what that actually means, I think really helped your team. And they already had so many wonderful elements. I think your nurses innately are extremely compassionate, very skilled,

When we talked about how to assess for causes of agitation, that was a big focus in the training. I think they sort of realized that they already knew how to do that. It was just in a different context with a patient that's nonverbal and has a lot more things that could be bothering them, such as an endotracheal tube.

But now, like you said, they already know. They're already managing these patients so well without even coming to you. They did their own troubleshooting. And the last option is sedation. But even when they use sedation, especially for agitation, it sounds like these patients are still awake and writing on clipboards. Yeah, it really is. I think walking through probably a couple of weeks ago, we had a very full, very sick, high acuity trauma ICU with several vented patients.

And walking through our ICU now and seeing the state of those patients compared to even a year, but definitely two, three, five years ago, so different, so different because those patients are awake. A lot of them are out of bed. They're in a chair. They're writing on clipboards. They're communicating with family. The nurses and the therapists and everybody have gotten so much more comfortable with finding nonverbal ways to communicate. I'm a big...

kind of eye gaze myself using the eyes because I have a daughter who communicates that way. But the nurses have gotten so creative. They'll use if a patient can't write or you can't read what they're writing that we had one patient who they had her point at a letter board with her foot because it was like the only extremity that wasn't all broken and bandaged and splinted and was functioning. And they like basically would go through. We didn't know who she was. And they had her spell out her name and give us her date of birth by pointing at it with her foot. And that was all nursing led.

And we never would have been able to do that in a patient that was as sedated as we used to sedate patients, especially with that many injuries. And she had some psychiatric history and some substance abuse history and a

a lot of that stuff we didn't know until we could identify who she was and look up more about her and learn about her. But it's definitely a difference and it's a different vibe when you see the majority of patients. And like you said, even the ones that are needing sedation and sometimes we may need it transiently for procedures or for something going on, but it's used in a much more targeted and specific approach. And the sedation that we reach for is very different than what it used to be used for, which is just that

patients need to be very somnolent when they're on the ventilator. And there's no longer that mentality, which is wonderful. Oh, and in the trauma population, you do have a lot of patients show up unidentified. Yeah, they all do. So, I mean, when a patient comes in as an activated trauma, they all come in with an unidentified trauma.

name, a generic name, our trauma name and a brand new medical record number, brand new account number. And if they can't tell us who they are and have there's some way to validate that their stuff doesn't get changed in the system. So patients that come in that are head injured or they're comatose or they get intubated right away, if they don't have family around and they're not able to communicate with us, we don't know who they are. And so they all come in, but not under their real name for the most part.

And the history is so important in managing their care. Yeah. Just like this situation you described where she had psych history, polysepsis abuse. That was important context to know how to manage her. Right. And yet we would miss all of that. And you mentioned that your daughter uses an AEC device. And so does my daughter. That's been a really sweet bond for us to talk about our daughters with special needs. Sorry. I hope that's okay. Yeah. Yeah. This is fine. So that's,

My journey with my daughter and using eye gaze technology for communication has really transformed my perspective of how we care for patients in the ICU. And I had spent years in a wake and walk in ICU well before my daughter, taking that for granted. And if they couldn't speak English, I was like, well, we'll just use the family. We'll just figure it out. We'll do charades or whatever. But I have a totally different perspective. And so when I see you and I realize how we...

culturally in the ICU, see people that are nonverbal, which are a lot of our patients, all vented patients, trach patients, they're nonverbal. And the assumption that they don't have anything to say or that we can't communicate with them, that hits me a totally different way now.

What's it like for you as well? Yeah, 100% just what you said. It's not only with our patients in the ICU who can't communicate because they're intubated, but even with my practice in patients like my daughter who may have certain special needs that has rendered them nonverbal. And it's so easy to underestimate people. And as you probably know, in the special needs community, there's a key phrase, which is presumed competence.

So we have to start with the presumption that they're there, that they comprehend, that they understand, that they're aware, that they know. It's just the output that is lacking. And so they're not able to communicate that well with you. And so then the burden is on the people with them. And in the health care setting, it's us to try to do the best we can to to allow them to express themselves with whatever tools we can.

So for me, I revert to the way that I communicate with my daughter a lot. She has a very high end technological device that is eye gaze controlled and we can't provide those for all of our patients. And not all of our patients can even use their hands and tap and use an iPad or a touchscreen. But a lot of patients can use their eyes or they can give us some sort of indication, even just starting with a basic yes, no, trying to figure out

Let's figure out a way that you can indicate yes and no to me and then go from there or spending a little extra time with those patients trying to read their lips, combination of lip reading and asking questions and clarifying questions to try to get at somebody's desires or what's going on with them, right? Assessing them or whatever. So it does give me a completely different perspective and level of patience and willingness to really get more creative and spend more time trying to figure that out because truly,

If the patient understands that you're understanding them or they have a say and they have a voice, I think they're so much easier to take care of. They're aligned with you. They're more willing to do what you want them to do, what you know might be or feel might be best for their care. And they're not fighting you every step of the way if they really feel like you're aligning with them and their goals. Having lived in other countries when I couldn't speak the language, it left me feeling so vulnerable, helpless, frustrated, irritable sometimes. And so...

That gave me a whole new perspective as well to say what is it like for them in this very vulnerable situation to not be able to communicate with those that are taking control of everything about their body and their lives. Right. And obviously, this is a skill set. So it sounds like your team is really developing that skill set of non-verbal communication. And it just blows my mind that we don't in intensivist training, nurse training, we

Even when we're onboarding into critical care, respiratory therapists who care for a lot of nonverbal patients, none of it. We don't get any nonverbal communication training. Right. So many of our patients are nonverbal and unverbal.

So I just look forward to this shift in the IC community in general, but also in society that just because someone doesn't have, can't talk, doesn't mean that they don't have something to say. Right. Again, that's just become really personal for me. I don't know if you've seen the movie Out of My Mind. I have read the book. I haven't yet seen the movie because I want to watch it with my daughter and her siblings. And we haven't had the opportunity yet since it's come out. But yes, we have read the book.

And I recommend that, you know, it's in the ICU as well, that this is the movie that it just shows you the perspective and of what's going on in someone's head, even when they're nonverbal. And we need to see our ICU patients the same way. Right. And maybe with traumatic brain injuries and things like that, obviously their cognition is going to be a little bit different, but let's assume competence first. Yeah. Yeah. I think that is the biggest thing. And

Not only that, but with level of alertness, because we know that our patients, even that are sedated or that are brain injured or that are comatose for whatever reason, they still have a sense of hearing and their brain is still doing something, even though we can't see from the outside what it's necessarily doing. And it's been a big reminder for me too, even in patients that

I expect we'll be able to communicate when they're awake. If they're not awake for whatever reason and they're in the ICU, be careful what you say in front of patients. Like I, now I walk into every room pretty much with the perspective that this patient, at least I tell myself this patient can hear what I'm saying and understand what I'm saying. So be careful what you're saying about them in front of family. That's one of my daughter's biggest sources of frustration is being talked about in front of her, but not included or not.

We're not talked to the point that when she's at doctor's appointments, if like the doctor and I are talking about something in front of her, even if it's not something that's really hurtful or a sensitive subject or anything, she gets very frustrated. She does not like it. She will start vocalizing. She doesn't have spoken language, but she'll start vocalizing to drown out the sound. And you can tell that she's okay. I don't really like what's happening here. And so I do try to intentionally, even if I'm not getting any output from the patient, try to do what I can to include the patient in the language. Or if it's something that I feel like

Probably if this patient was wide awake, wouldn't want to hear or maybe shouldn't be involved in this conversation, ask the family to step out because it's so easy to just talk about somebody in front of them, assuming that they don't understand or they don't hear. And maybe they do. This whole all of these practices have been mind opening in that regard to learning about what patients brains do under sedation. They still hear things and then their brain makes a crazy, terrifying noise.

scenarios to explain it because they're not really tethered anymore to reality because of sedation or their injury. And so it's made me much more cognizant of patient's awareness in lots of situations. Yeah, that's one of the main things that I wish I could go back and change. You know, for many years of practice, not knowing this information.

patients with altered level of consciousness, even when they're not sedated, they have hypoactive delirium. We just, I think about times when we were doing procedures and we're talking about, you know, body habit isn't, things are just logistical that we have to figure out. But we, I know that I didn't, I wasn't being very mindful of what they could hear and how that might be interpreted on their side. Right. But all we can do is move forward. And that's what I love seeing your team do is just moving forward, learning from the past, but

building a better future. And so when you walk on your unit, most of your patients are awake, even sitting in chairs, running, walking the halls if they can, standing on the verticalization beds. And it's just amazing to hear your nurses. You're just now listening in, go back and listen to episode 185 to hear the nurse's side of all of this. But

Truly, Dr. Coates, your team wouldn't be where they're at without your incredible leadership. I learned a lot about what a medical director really can accomplish.

I appreciate that. I appreciate you saying that. I think that they, I think they probably would get there regardless. And because we also have some amazing other voices and physicians and nurses that have been passionate about this even since before. I was excited to do this within our unit and really push for it. One, because like I told you once I knew I couldn't not know. And so then it just didn't, it wasn't even a question of, are we going to do this? It was just, we have to do this. How are we going to make this happen? But

The trauma ICU, I think, as the nurses will tell you, and almost anybody who works in trauma will tell you, is unique for a few particular reasons. And every place has its nuances. But trauma's hard to think about making these big changes in because patients are broken and patients come in with very complicated histories and past. And you get that on all fields, for sure. It's not like you don't get complex patients or patients with psych history or patients with substance abuse history or patients with homelessness.

in other ICUs, but it's really just the incidence of it is pretty high in trauma and it complicates all this stuff. But what I've found just in seeing it done more and more and more is it seems like

The more complicated the patient is with regard to all the things that we thought would make it impossible to do these things, the bigger the reward and the easier they are compared to what it would have been if you didn't do these things. So if they come in already with five different substances positive on their tox screen and three different site diagnoses, none of which have had meds for the last two years,

and you sedate them, it's going to make it even worse. And then it's like a month, month and a half of them hurting themselves, hurting other people, kicking, meeting restraints, not, not being able to reason with them, yelling at them. It just, it becomes so much more complicated than if we try to let all the stuff they come in with get out of their system, support them through any sort of withdrawal or rehab, get psych on board early and social work, especially

Especially if we know the patient and we know their history to try to get them adequately treated or get some assistance in that regard, but then not worsen things. It helps a lot. And the nurses are passionate. Like you said, one of my funniest and fondest memories was one of my very first nights in the ICU. I was actually moonlighting at Mercy San Juan as a fellow nurse.

And I came into the ICU after I had operated on a patient and I was not a familiar face around there. And so one of our strong ICU night nurses, who is now our critical care educator,

was like not about to let me near that patient's bed because she didn't know who I was. When I walked in, I didn't really introduce myself and I walked in and started asking questions and she's like, I'm sorry, you are? Something like that. And then when I introduced myself, she was like, she was so sheepish and she was so embarrassed. And I was like, no, I'm sorry. I didn't, yeah, you had no idea who I was, but they're so protective. They're protective of their patients.

And they're strong personalities and they all want to do the right thing for the right reason. And there's a lot of energy behind what they do. So I knew once people realized what is the right thing to do in these situations, now that we know what we know about our practices, it would be in some ways, yeah, you might get some resistance up front. But once people get behind it, there's no stopping the nurses on teams like this. So that's really exciting.

And one of my objections with training is that the culture and these practices don't just hinge on one person. Right. You're not there today, but they're doing the right things today. Right. And so not that you're going to leave, but if you were to, those nurses, especially that we interviewed in episode 185, they're not going to let this drop. They are so protective of their patients.

that they will keep running the ship, which is so nice that day and night shift, all disciplines, everyone's working towards the same goal. And that's what's making this so feasible. And hopefully, I feel very confident that it will be sustainable. Yeah, as you guys are cracking the code.

I do think that we have passed that tipping point, I think, and not just in the trauma ICU, but it feels like to me across most of the hospital and most of the other ICUs too, is it's no longer about like, okay, we're supposed to do this thing and how are we going to make it happen? And are we going to be able to make it happen now? It's just that like, wait, no, this is what we do. What do you mean? And I've seen some small little things even recently where we may have somebody who comes in, maybe a traveler or somebody who has not been exposed to a lot of these practices and they're

I don't want to say police, they're supported appropriately by their colleagues too and by other nurses. We had a patient who was a head injury on top of a head injury on top of new injuries a few months ago. And it was frustrating sometimes to take care of him because it was very repetitive and also very active and wanting to get up and wanting to move around. And so he was busy. He was a busy patient for a nurse. And then

And the nurse that had him at the time was starting to get frustrated. And other nurses were ones that would step in and be like, he doesn't, he's not trying to be that way. They were intervening on the patient's behalf, but then also offering to be like, hey, why don't we, I got to finish this up with my other patient. And then why don't we get, I'll help you. Let's get him up. Let's get him to a chair. Let's take him outside. Maybe it'll wear him out and then he'll sleep better tonight. So.

It's really exciting and heartwarming to just be sitting in the ICU charting and see some of these things happening and just be like, ah, they're so good. It's just a place, it gives you so much pride to work in a place like that when you see what can be. Well, I told the nurses, you're going to have all these applicants trying to work at Marcy's Canapon Dignity Health in Sacramento or Carmichael in California, because this is a dream. This is why people get into the ICU and the fact that you guys have been able to

build this kind of environment in a short amount of time. I'm excited to hear what's happening

A year from now, I want you guys presenting at conferences because there's a precedent set for trauma critical care in your ICU. Yeah, very exciting. And we love our patients to come back. We have a trauma survivor's day every year. And so some of the nurses that are the most passionate about these things too get very involved in the trauma survivor's day too. And they're already like identifying, we got to get this person back for trauma survivor's day. And it's such a touching thing to see what happens to our patients. And so I think that's why these stories make such a big impact when we hear how patients survive

often turned out after historically how we manage things in the ICU versus how they can be when we manage things this way in the ICU because everybody loves those success stories and seeing how patients are doing a year later, two years later, just amazing compared to what they were like in the ICU. I hope your current team and your future clinicians never take this for granted.

Yeah, the fact that I could work seven years plus and in a week walk in ICU and not know the value of what I was doing because it was so normal. Right. I hope that never happens. I hope you guys are able to always realize taking that person outside or getting them up at the side of the bed. That was saving their lives. That's protecting their brains. That's getting them back to work. I hope they always are able to see the value and how bad a these interventions are, even and especially as they become so routine and normal.

Right. Hope it never loses its magic. Yeah, I hope so too. I'm sure it will. I'm sure it will because it just becomes more routine when you don't even realize what things, but it'll be one of those things where some of us date ourselves as physicians be like, well, when I first started my practice, we used to date everybody on a ventilator. You know, everyone will be like, wow. Yeah. Wow. Any last recommendations that you would give to

other people in trauma, medical directors that are wanting to embark on this journey? I think we covered most of it. I think do whatever you can to try to find a way to change the system and the culture and things as a whole and not just be trying to bark from a corner. It just doesn't work very well.

And then I think just the more you can do to continue to talk about the benefits and frame how it's going to be, frame expectations. I now individual patients, I would talk to their families about it too, so that the families aren't alarmed if they come in and I'll say, you know, we know now it's crazy, but we used to give people these strong sedating medications to keep them asleep on the ventilator. And then we realized we weren't actually helping them that much by doing that. And so we're going to really try to keep your mom as awake as possible. We want her to communicate with us. We're going to try to, we're going to,

control her pain, but don't be surprised if they're getting her up tomorrow morning. And so we really set the expectations for everybody. But in terms of going from where we were to where we are and where I know we'll continue to strive for, it's a process and the nurses are already there in terms of their mindset of their goals. So even if they don't know it and the therapists and the other doctors, because everybody wants this thing at the end, um,

It just, they do need the resources. So figure out what can be done to provide the resources for the hospital to support the teams that are already doing the clinical work. Because yeah, like we said, if you just put it in their lap that this is the expectation and now you need to make it happen, it won't happen. Yeah.

And I told, I warned that they would have a mutiny on their hands. Yes. And they tried it that way. And I still stand by that. I think this is especially post COVID. We have to be careful about bringing on that kind of expectation. But even by the time, it was six months after we had launched that the

mobility techs actually came on and your team was already doing this. I still stand by the mobility techs. I still think they're amazing return on investment and they're being used and they will be for many years to come. And that would have happened if we hadn't spoken the financial benefit language to the administration. So this is the best way to advocate for safe staffing or more education, more equipment, those kinds of things by spelling out the financial benefits. And I would have had that opportunity if

there weren't strong revolutionists and leadership there begging and demanding for these changes. So congratulations on everything you've accomplished over the last few years, Dr. Coates. This is an accomplishment of a lifetime. So congratulations. Well, it has been, it's been really wonderful to see and be a part of that. Yeah, I'm excited for whatever comes next. Well, keep us posted. Yes, thank you. Thank you so much. Thank you. Thank you.

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